Inverted nipples

What should I know about inverted nipples?

In women with inverted nipples, the nipple root is tight instead of stretchy. There are three grades of severity. There are multiple possible causes. Among them are engorgement, breast surgery, and chest trauma. Inverted nipples may also be caused by a disease such as cancer, mastitis, or an abscess. Most commonly, however, women with the condition are born with it. They have a cord of fibrous tissue that connects the nipple to the tissues of the breast. The shorter, tighter, or thicker the cord, the more the nipple is tied down onto the breast and the more trouble the baby will have latching and getting milk. Mothers may also have nipple pain and damage. Depending on the cause, a mother may have one or both nipples inverted.

A) Describing an inverted nipple

The nipple root of most breasts is soft and stretchy. The results of a pinch test on these breasts will be normal.

Inverted nipples can look pulled into the breast. The root is not stretchy but is hard and tight. Using the pinch test, a rope of tissue (cord) will be felt running from inside the nipple, through the nipple root, back into the breast. 

There are three grades of inverted nipples and they can cause a variety of breastfeeding problems. At their worst, babies are unable to latch. There are a number of management and treatment options.

Inverted nipples do not usually block the flow of milk out of the breast and mothers can express if needed.

B) Causes of inverted nipples

1) Congenital inverted nipples

In most cases of inverted nipples, women are born with them (congenital). An estimated 1.8 to 3.3% of women have inverted nipples (Park 1999; Schwager 1974).

The condition becomes apparent at puberty and is the most common cause of inverted nipples.

2) Other causes of inverted nipples

Inverted nipples may be caused by:

Severe engorgement can draw the nipple into the breast as well as cause swelling of the nipple root.

Depending on the cause, a mother may have one or both nipples inverted. Mastitis, breast abscesses, and cancer generally affect only one breast and can cause one nipple to suddenly invert. If you have noticed this, please see your health-care provider as soon as possible.

C) Types of inverted nipples

There are different ways of classifying inverted nipples (Han 1999).

One simple method is based on the way the nipple root works and responds to the pinch test. The appearance is not important as some inverted nipples look fairly normal and some normal nipples look inverted.

The higher the grade, the more breastfeeding problems are likely.

1) Grade 1 inverted nipples

This includes shy or dimpled nipples. 

The resting position of these nipples is tucked in but they feel normal using the pinch test. They will evert with the pinch test, breastfeeding, and expressing. As they are not used to this position, they can quickly become tender or damaged

Babies can generally latch and breastfeed well on these nipples. Shy nipples might need to be everted before latching.

2) Grade 2 inverted nipples

These can also be called partially inverted nipples.

Grade 2 inverted nipples may look:

  • Normal
  • Flat
  • Slightly inverted
  • Fully inverted
  • Dimpled

The pinch test on these nipples will show a thickening or cord in the nipple root, making it hard to pull the nipple out of the breast. The nipple feels tied down and not very stretchy. Some are more tied down and others less so. 

With these nipples, there is a significant risk that the baby will not be able to latch and nipple pain and damage.

The sandwich technique is often used to make the nipple root stretchier, to help a baby latch, or to treat painful and damaged nipples. However, it should not be used if the nipples are partially inverted. That’s because it involves pressing on the breast, which shortens the cord holding the nipple down. That makes the nipple more inverted and makes latching harder.

 3) Grade 3 inverted nipples

The truly inverted nipple is classified as Grade 3. It looks hidden inside the breast. In the pinch test, the nipple root is impossible to hold between the finger and thumb. These are less common than Grade 1 and 2 inverted nipples.

Babies cannot latch onto a truly inverted nipple and they may damage the nipple while trying. The mother’s only option to feed her baby breast milk is to express.

D) Options for feeding your baby

Shy nipples may need to be everted before latching. Babies should not have difficulty latching onto dimpled ones.

If your baby cannot latch because your nipples are inverted, you can feed your baby by:

Nipple shields are only helpful if the nipples are slightly inverted. The more inverted the nipple, the less likely it is that a nipple shield will be effective as the nipple cannot enter the nipple shield cone.

Tube-at-the-breast systems are not useful if the baby cannot latch properly because of inverted nipples. To use one, the baby must be able to latch onto the breast and suck with the tube in place.

References

Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg. 1999 Aug;104(2):389-95; discussion 396-7
 
Park HS, Yoon CH, Kim HJ. The prevalence of congenital inverted nipple. Aesthetic Plast Surg. 1999;23: 144–146
 
Schwager RG, Smith JW, Gray GF, et al. Inversion of the human female nipple, with a simple method of treatment. Plast Reconstr Surg. 1974;54: 564–569